# Clinical Response to Perinatal Depression Screening — ACOG 2018

## Core Principle

ACOG states that **screening alone can have clinical benefits**, although **initiation of treatment or referral to mental health care providers offers maximum benefit**. Clinical staff in obstetrics and gynecology practices should be prepared to **initiate medical therapy, refer patients to appropriate behavioral health resources when indicated, or both**.

## Systems Approach to Screening and Follow-Up

Screening must be implemented with adequate systems in place to ensure:

1. **Accurate diagnosis** following a positive screen
2. **Effective treatment** initiation (pharmacotherapy, psychotherapy, or both)
3. **Appropriate follow-up** to monitor treatment response
4. **Referral pathways** to mental health specialists when needed

Screening without a structured system for follow-up has limited clinical utility and may cause harm through false reassurance or unaddressed positive results.

## Clinical Response Algorithm

### If Screen is Negative (EPDS < 10, PHQ-9 < 10)

- Provide **psychoeducation** about perinatal mood disorders (signs and symptoms to watch for).
- Provide written materials on perinatal depression and local resources.
- Continue **routine screening** at subsequent prenatal visits and at the comprehensive postpartum visit.
- If risk factors are present, consider more frequent monitoring.

### If Screen is Positive (EPDS >= 10 or PHQ-9 >= 10)

**Immediate actions:**
- Conduct a **clinical assessment** to determine symptom severity and functional impact.
- Assess for **suicidal ideation, homicidal ideation, and psychotic symptoms**.
- Screen for **bipolar disorder** (MDQ) before initiating antidepressant therapy.
- Discuss screening results using a **strength-based framing**, emphasizing that perinatal depression is common, treatable, and a medical condition.

**Based on severity:**

#### Mild Depression (EPDS 10-12, PHQ-9 10-14)
- **First-line**: Psychotherapy alone
  - **Cognitive Behavioral Therapy (CBT)**: Evidence-based for perinatal depression; focuses on identifying and restructuring negative thought patterns.
  - **Interpersonal Therapy (IPT)**: Evidence-based for perinatal depression; focuses on role transitions, interpersonal conflicts, and social support.
- Repeat screening in **2-4 weeks** to monitor trajectory.
- If symptoms persist or worsen after 4-8 weeks of psychotherapy, consider adding pharmacotherapy.

#### Moderate Depression (EPDS 13-19, PHQ-9 15-19)
- **Recommended**: Combined psychotherapy (CBT or IPT) and pharmacotherapy.
- Alternatively, either psychotherapy or pharmacotherapy alone may be offered based on **patient preference and shared decision-making**.
- Initiate follow-up within **1-2 weeks** of treatment initiation.
- Reassess in **4-6 weeks** for treatment response.

#### Severe Depression (EPDS >= 20, PHQ-9 >= 20)
- **Initiate pharmacotherapy** promptly.
- **Refer for psychotherapy** concurrently.
- Consider **urgent psychiatric referral** or consultation.
- Close follow-up within **1 week** of treatment initiation.

#### Depression with Psychotic Symptoms or Active Suicidal/Homicidal Ideation
- This constitutes a **psychiatric emergency**.
- Initiate immediate **safety planning** and crisis intervention.
- **Emergent psychiatric evaluation** is required.
- Hospitalization may be necessary.
- Antidepressant monotherapy is insufficient; antipsychotic medication and/or electroconvulsive therapy may be indicated.

## Pharmacotherapy

### Preferred Agents

ACOG notes that **selective serotonin reuptake inhibitors (SSRIs)** are first-line pharmacotherapy for perinatal depression. SSRIs have the most extensive safety data in pregnancy and lactation.

| Medication | Class | Notes |
|---|---|---|
| **Sertraline** | SSRI | Preferred first-line; lowest transfer into breast milk; most reassuring safety data during pregnancy and breastfeeding |
| **Escitalopram** | SSRI | Preferred first-line alternative; favorable safety profile |
| **Fluoxetine** | SSRI | Effective but longer half-life may complicate management |
| **Citalopram** | SSRI | Acceptable alternative |

### Prescribing Principles
- Use the **lowest effective dose**.
- If the patient was previously treated successfully with a specific antidepressant, **restart the same medication** rather than switching.
- **Continue treatment for at least 6-12 months** after symptom remission to prevent relapse.
- Abrupt discontinuation should be avoided due to risk of **discontinuation syndrome** and relapse.

### Second-Line Agents
- **SNRIs** (e.g., venlafaxine): If SSRI is ineffective or not tolerated.
- **Bupropion**: Atypical antidepressant; may be considered for patients with fatigue or those who wish to avoid sexual side effects.
- **Tricyclic antidepressants**: Third-line option.

### Breastfeeding Considerations
- The risk of breastfeeding while taking an SSRI is **relatively low**, and patients can be **encouraged to breastfeed** while on antidepressants.
- Sertraline and paroxetine have the **lowest levels of transfer** into breast milk.
- The benefits of breastfeeding and of treating maternal depression generally outweigh the risks of infant medication exposure.

## Psychotherapy

Psychotherapy is the **first-line treatment option** for patients with mild to moderate perinatal depression.

### Evidence-Based Modalities
- **Cognitive Behavioral Therapy (CBT)**: Strong evidence for efficacy in perinatal depression.
- **Interpersonal Therapy (IPT)**: Strong evidence; particularly suited to the role transitions and interpersonal challenges of the perinatal period.
- **Support groups**: Can be a valuable adjunct to individual therapy.

### Access and Delivery
- Psychotherapy may be delivered **in person or via telehealth**.
- Barriers to access include cost, availability of trained therapists, childcare, and transportation.

## Referral Criteria

Referral to a **mental health specialist** (psychiatrist, psychologist, or licensed therapist) is indicated when:

- **Severe depression** (EPDS >= 20 or PHQ-9 >= 20)
- **Suicidal or homicidal ideation**
- **Psychotic symptoms** (hallucinations, delusions, disorganized behavior)
- **Bipolar disorder** suspected or confirmed (MDQ positive)
- **Failure to respond** to initial treatment within 4-8 weeks
- **Substance use disorder** comorbidity
- **Complex psychiatric presentation** (multiple comorbid conditions)
- The obstetric provider is **not comfortable managing** the psychiatric condition

## Follow-Up

- Reassess symptoms using the **same validated instrument** used for initial screening.
- Monitor treatment adherence, side effects, and therapeutic response.
- Plan for **continuation of treatment** through the postpartum period, as the highest-risk period for relapse is the first 6 months postpartum.
- Coordinate care between obstetric, psychiatric, and pediatric providers.
- Ensure patients have **access to emergency resources** (crisis hotlines, emergency department instructions).

## Limitations

- ACOG Committee Opinion 757 focuses primarily on **screening** rather than providing detailed treatment protocols. For comprehensive treatment guidance, refer to ACOG Clinical Practice Guideline No. 5 (2023): Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum.
- The optimal frequency and timing of screening beyond "at least once during the perinatal period" is not precisely specified.
- Access to mental health services varies significantly by geographic region, insurance coverage, and socioeconomic status, creating implementation barriers.
- Pharmacotherapy recommendations are general; individualized treatment decisions should account for patient preference, prior treatment history, and risk-benefit analysis.
