# Risk Factors and Clinical Assessment for Perinatal Depression — ACOG 2018

## Definition of Perinatal Depression

Perinatal depression includes **major and minor depressive episodes** that occur during pregnancy or in the **first 12 months after delivery**. It encompasses both prenatal (antenatal) depression and postpartum depression as a continuum of the same clinical entity.

## Prevalence

- Perinatal depression is one of the **most common medical complications** during pregnancy and the postpartum period.
- It affects approximately **1 in 7 women** (approximately 14%).
- Prevalence estimates range from **6.5% to 20%** depending on the population studied, geographic region, and diagnostic criteria used.
- Perinatal depression is **underdiagnosed and undertreated** — many women do not disclose symptoms or seek care due to stigma, lack of awareness, or normalizing symptoms as part of pregnancy or new motherhood.

## Risk Factors for Perinatal Depression

ACOG identifies the following risk factors that increase susceptibility to perinatal depression:

### Psychiatric History
- **Personal history of depression** or anxiety (strongest predictor)
- **Prior episode of perinatal depression** or postpartum depression
- **Family history of psychiatric disorders** (depression, bipolar disorder)
- **Premenstrual dysphoric disorder** or premenstrual syndrome

### Psychosocial Factors
- **Current stressful life events** (job loss, bereavement, financial hardship, relocation)
- **Lack of social support** or perceived inadequate support
- **Intimate partner violence** (physical, sexual, or emotional abuse)
- **Unintended or unplanned pregnancy**
- **Adolescent pregnancy**
- **Relationship difficulties** or single parenthood

### Obstetric and Medical Factors
- **History of pregnancy loss** or infertility
- **High-risk pregnancy** or pregnancy complications
- **Preterm birth** or low birth weight infant
- **Traumatic delivery** (emergency cesarean section, NICU admission)
- **Breastfeeding difficulties**
- **History of type 1, type 2, or gestational diabetes**

### Sociodemographic Factors
- **Low socioeconomic status**
- **Limited access to healthcare**
- **Racial and ethnic disparities** in screening and treatment access
- **Immigration status** and associated stressors

## Clinical Assessment After Positive Screen

When a patient screens positive on the EPDS (score >= 13) or PHQ-9 (score >= 10), a structured clinical assessment should follow:

### Step 1: Confirm and Characterize Symptoms
- Conduct a **clinical interview** to assess the nature, severity, duration, and functional impact of depressive symptoms.
- Assess symptoms against **DSM-5 criteria** for major depressive disorder, with the perinatal onset specifier.
- Differentiate from **"baby blues"** — transient mood lability and tearfulness in the first 2 weeks postpartum that is self-limited and does not meet criteria for a depressive episode.

### Step 2: Evaluate Safety
- **Suicidal ideation**: Directly assess for suicidal thoughts, plan, intent, and access to means. Any endorsement of self-harm on the EPDS (item 10) or PHQ-9 (item 9) requires immediate safety evaluation.
- **Homicidal ideation**: Assess for thoughts of harming the infant or others.
- **Psychotic symptoms**: Screen for hallucinations, delusions, or disorganized thinking — these may indicate **postpartum psychosis**, a psychiatric emergency requiring immediate intervention.

### Step 3: Assess Functional Impact
- Evaluate the impact on **maternal-infant bonding**, breastfeeding, self-care, and daily functioning.
- Assess impact on **the partner relationship** and family dynamics.
- Determine whether the patient is able to **safely care for herself and her infant**.

### Step 4: Identify Comorbidities
- Screen for **anxiety disorders** (generalized anxiety, panic disorder, OCD) — anxiety frequently co-occurs with perinatal depression.
- Screen for **bipolar disorder** using the Mood Disorder Questionnaire (MDQ) — approximately **1 in 5 women who screen positive for depression may have bipolar disorder**. This distinction is critical because antidepressant monotherapy is **contraindicated** in bipolar disorder and may precipitate mania.
- Screen for **PTSD** related to traumatic birth experience or prior trauma.
- Assess for **substance use disorders**.

### Step 5: Determine Severity and Guide Management
- **Mild depression**: Consider psychotherapy alone (CBT or IPT) as first-line.
- **Moderate depression**: Consider combined psychotherapy and pharmacotherapy, or either alone based on patient preference.
- **Severe depression**: Initiate pharmacotherapy and psychotherapy; consider urgent psychiatric referral.
- **Depression with psychotic features or suicidal/homicidal ideation**: Immediate psychiatric emergency evaluation.

## Special Populations Requiring Close Monitoring

ACOG identifies the following groups as warranting particularly close monitoring, evaluation, and assessment:

- Women with **current depression or anxiety**
- Women with a **history of perinatal mood disorders**
- Women with **risk factors for perinatal mood disorders**
- Women with **suicidal thoughts**
- **Adolescent** pregnant and postpartum patients
- Women with **substance use disorders**

## Limitations

- Risk factor assessment alone is **insufficient** for identifying perinatal depression — many women without identifiable risk factors develop depression, and many with multiple risk factors do not. Universal screening is therefore preferred over selective, risk-factor-based screening.
- The "baby blues" affects up to **80%** of postpartum women and must be distinguished from clinically significant depression. The key differentiator is that baby blues **resolve within 2 weeks** without treatment.
- Cultural factors may influence the expression and reporting of depressive symptoms. Clinicians should be sensitive to culturally specific presentations of distress.
