# Screening for Perinatal Depression — ACOG 2018

## Screening Recommendation

The American College of Obstetricians and Gynecologists (ACOG) recommends that obstetrician-gynecologists and other obstetric care providers **screen patients at least once during the perinatal period** for depression and anxiety symptoms using a standardized, validated tool.

- All obstetrician-gynecologists and other obstetric care providers should complete a **full assessment of mood and emotional well-being** (including screening for postpartum depression and anxiety with a validated instrument) during the **comprehensive postpartum visit** for each patient.
- If a patient is screened for depression and anxiety during pregnancy, **additional screening should then occur during the comprehensive postpartum visit**.

## Validated Screening Instruments

ACOG endorses the use of validated, standardized screening tools. The two primary instruments recommended for perinatal depression screening are:

### Edinburgh Postnatal Depression Scale (EPDS)

| Feature | Detail |
|---|---|
| **Items** | 10 questions |
| **Scoring** | Each item scored 0-3; total range 0-30 |
| **Standard clinical threshold** | Score >= 13 indicates probable depression |
| **Screening threshold** | Score >= 10 used when sensitivity is prioritized |
| **Unique feature** | Addresses the anxiety component of perinatal mood and anxiety disorders as well as depressive symptoms |
| **Self-harm item** | Item 10 assesses thoughts of self-harm; any positive response warrants immediate safety assessment |
| **Validation** | Originally validated for postnatal use; subsequently validated for antenatal screening |

> **OpenMedicine Calculator:** `calculate_epds` -- available via MCP for automated EPDS scoring.

### Patient Health Questionnaire-9 (PHQ-9)

| Feature | Detail |
|---|---|
| **Items** | 9 questions based on DSM diagnostic criteria |
| **Scoring** | Each item scored 0-3; total range 0-27 |
| **Screening threshold** | Score >= 10 indicates positive screen |
| **Unique feature** | Maps directly to DSM criteria for major depressive disorder |
| **Limitation** | Does not include the anxiety component that the EPDS captures |
| **Suicidal ideation** | Item 9 assesses suicidal ideation; any positive response warrants immediate safety assessment |

> **OpenMedicine Calculator:** `calculate_phq9` -- available via MCP for automated PHQ-9 scoring.

### Choosing Between EPDS and PHQ-9

- The **EPDS** is specifically designed for the perinatal population and captures anxiety symptoms alongside depressive symptoms and suicidal thoughts.
- The **PHQ-9** incorporates DSM diagnostic criteria but **lacks the anxiety component**.
- Either instrument is acceptable; the choice depends on clinical context and whether anxiety screening is desired as part of the same instrument.

## Screening Timing and Frequency

ACOG recommends screening at multiple points during the perinatal period:

1. **Early in pregnancy** (first prenatal visit) -- to detect pre-existing or pregnancy-onset depression
2. **Later in pregnancy** -- to identify symptoms developing during gestation
3. **Comprehensive postpartum visit** -- mandatory reassessment even if screened during pregnancy

Women with **current depression or anxiety, a history of perinatal mood disorders, or risk factors for perinatal mood disorders** warrant particularly close monitoring, evaluation, and assessment, and may require **more frequent screening**.

## Implementation Considerations

- Screening tools can be administered by **clinical support staff** during check-in or rooming.
- Instruments should be **scored before the patient departs** to enable immediate clinical intervention if needed.
- Scores should be documented in the **electronic health record** and communicated to the licensed provider.
- Screening must be implemented within a **system of care** that includes educated providers, social support, and a follow-up protocol for patients who screen positive.

## Limitations

- Screening tools identify individuals at risk but **do not constitute a diagnosis**. A positive screen requires comprehensive clinical evaluation to confirm or rule out a depressive disorder.
- No single screening tool captures all perinatal mood and anxiety disorders. ACOG notes that additional screening for **anxiety (GAD-7), bipolar disorder (MDQ), and PTSD (PC-PTSD)** may be appropriate.
- The EPDS and PHQ-9 may have reduced sensitivity in certain cultural contexts or when language barriers exist, though both are available in multiple languages.
- Screening without a system for **follow-up, treatment, or referral** has limited clinical utility.
