Depression during pregnancy and the postpartum period—Clinician FAQ

Recommendation

As part of usual care, providers should remain attentive to patient mental health during visits.

However, the Canadian Task Force on Preventive Health Care recommends against  universal screening for depression using standardized tools, such as questionnaires with a cut off, with all pregnant and postpartum people (up to 1 year after birth)

(conditional recommendation, very low-certainty evidence)

Key Points:

• This recommendation assumes that usual care during pregnancy and the postpartum period includes inquiry and attention to mental health and well-being during visits. Questions integrated into this usual care based on clinical judgment do not constitute a screening.
• Screening in this context is the use of standardized instruments, such as questionnaires, and using a cut-off score as a threshold to determine who needs further evaluation.
• In the judgement of the Task Force, screening would consume resources otherwise needed for individuals who have mental health concerns and for those diagnosed with mental health disorders.
• Attention to the mental health of patients should remain a focus for providers, but there is uncertain evidence that screening, as defined above, would improve mental health outcomes compared to usual clinical care.

1. Why does the Task Force recommend not screening?

• Available evidence is uncertain and does not establish additional benefits to screening all patients using standardized instruments with cut-off scores compared to usual clinical care.
• Screening could lead to unnecessary referrals and evaluation as well as increases in:
  • False positives screens, where patients meet the cut-off score but are found not to meet the diagnostic criteria for depression upon further evaluation
  • False negative screens, where patients do not meet the cut-off score, but actually have clinical depression
  • Overdiagnosis, where patients with mild, temporary symptoms are sent for further referral, evaluation, or treatment, but do not benefit since the symptoms would have subsided on their own in a similar time period.
• Redirection of mental health resources away from patients who often cannot access sufficient services could be an unintended harm.
• The Task Force is mindful of resource constraints and as such recommends against interventions when there are clear resource implications and benefits are unproven.

2. Who does this recommendation apply to?

• Pregnant people and those up to 1 year postpartum.

3. Who does this recommendation not apply to?

• Individuals with a personal history or current diagnosis of depression or another mental health disorder.
• People currently receiving assessment or treatment for mental health disorders.
• People receiving care in psychiatric or other mental health settings.
• People seeking services due to symptoms of depression.

4. What are some of the effects of postpartum depression?

• Depression during the postpartum period can have far-reaching impacts:
• On parent: Increased likelihood of anxiety or depression, increases in risky behaviours, lower quality of life, and suicidal ideation
• On infants: Physical and mental developmental delays and overall health concerns
• On parent-infant interaction: Reduced breastfeeding and poor maternal-infant bonding

5. How can I implement this recommendation?

• Instead of screening all patients with a standardized instrument in primary care, continue to focus your time and effort on your usual clinical care for this population.
• This should include asking patients about their mood and mental health during primary care visits in pregnancy and the postpartum period.
• Questions integrated into this usual care do not constitute a screening.

6. What if my clinic/hospital policy is to screen patients?

• The Task Force is aware that screening practices currently vary across Canada. We suggest that jurisdictions which have implemented screening reconsider its use given lack of proven benefits.