Screening for anxiety disorders in third trimester pregnancy: a comparison of four brief measures.

Evidence regarding the accuracy of existing anxiety screeners used in pregnancy is limited. This study compares the psychometric characteristics of the Generalized Anxiety Disorder 2- and 7-item Scales (GAD-2 and GAD-7), the anxiety subscale of the Edinburgh Postnatal Depression Scale (EPDS-3A) and the two anxiety items of the Antenatal Risk Questionnaire (ANRQ-2A). Nine hundred fifty-four women completed the screening measures and anxiety modules of a diagnostic reference standard (SAGE-SR) in the third trimester. Test performance characteristics of each measure was assessed using Receiver Operator Characteristic (ROC) analysis. We applied four previously recommended criteria to ascertain the value of each measure for widespread clinical use: area under the curve (AUC ≥ 0.8, Youden's index ≥ 0.5, negative predictive value (NPV) ≥ 0.8 and positive likelihood ratio (LR +) ≥ 4.0). Prevalence for any SAGE-SR anxiety disorder was 3%. All measures yielded an acceptable AUC of ≥ 0.8, Youden's index of ≥ 0.5 and NPV of ≥ 0.8. Only the EPDS-3A, at a cut-point ≥ 5, also achieved a LR + of ≥ 4.0 (4.35) but at this cut-point sensitivity was less than 0.75. The ANRQ-2A, at its optimal cut-point of ≥ 6, was the only measure to additionally attain both a sensitivity and specificity of ≥ .75. This study expands the evidence base for brief anxiety screening measures in the maternity setting and provides empirical support for the use of the EPDS-3A and ANRQ-2A in routine screening programmes. Studies assessing the performance of these measures in samples with higher disease prevalence and broader socio-economic status are warranted.

Detection and management of mood disorders in the maternity setting: the Australian Clinical Practice Guidelines.

BACKGROUND: Mood disorders arising in the perinatal period (conception to the first postnatal year), occur in up to 13% of women. The adverse impact of mood disorders on mother, infant and family with potential long-term consequences are well documented. There is a need for clear, evidence-based, guidelines for midwives and other maternity care providers. AIM: To describe the process undertaken to develop the Australian Clinical Practice Guidelines for Depression and Related Disorders in the Perinatal Period and to highlight the key recommendations and their implications for the maternity sector. METHOD: Using NHMRC criteria, a rigorous systematic literature review was undertaken synthesising the evidence used to formulate graded guideline recommendations. Where there was insufficient evidence for recommendations, Good Practice Points were formulated. These are based on lower quality evidence and/or expert consensus. FINDINGS: The quality of the evidence was good in regards to the use of the Edinburgh Postnatal Depression Scale and psychological interventions, but limited as regards medication use and safety perinatally. Recommendations were made for staff training in psychosocial assessment; universal screening for depression across the perinatal period; and the use of evidence based psychological interventions for mild to moderate depression postnatally. Good Practice Points addressed the use of comprehensive psychosocial assessment--including risk to mother and infant, and consideration of the mother-infant interaction--and gave advice around the use and safety of psychotropic medications in pregnancy and breastfeeding. In contrast to their international counterparts, the Australian guidelines emphasize a more holistic, woman and family centred approach to the management of mental health and mood disorders in the perinatal setting. CONCLUSION: The development of these Guidelines is a first step in translating evidence into practice and providing Australian midwives and other maternity care providers with clear guidance on the psychosocial management of women and families.

Depressive and anxiety disorders in the postpartum period: how prevalent are they and can we improve their detection?

The objectives of this study were: (1) to examine Composite International Diagnostic Interview (CIDI) period prevalence and comorbidity for depression and anxiety disorder in a cohort of women assessed during the first 6-8 months postpartum and (2) to examine the benefits of combining the Edinburgh Postnatal Depression Scale (EPDS) with a simple "interval symptom" question to optimize screening postpartum. Women aged over 18 (N = 1,549) were assessed during late pregnancy and reviewed at approximately 2, 4, and 6-8 months postpartum using the EPDS and an "interval symptom" question. The latter asked about any depressive symptoms in the interval since the last EPDS. Women who scored >12 on the EPDS and/or positive on the "interval symptom" question were then administered the CIDI. A further 65 randomly selected women that screened negative were also administered the CIDI. Loss to postnatal follow-up was very significant, and returns rates were inconsistent across the three postnatal time points. Almost 25% of those who screened positive did not complete a CIDI. For screen-positive status, a total of 314 (24.4%) of those that returned questionnaires (N = 1,289) screened positive at least once across the 6- to 8-month interval. Of these, 79 were lost to follow-up; thus, 235 (74.8%) completed a CIDI. In this group, 34.7% had been positive both on the EPDS and the "interval" question, 15.9% on the EPDS alone, and 49.4% on the "interval" question alone. For the CIDI diagnosis and estimated 6- to 8-month period CIDI prevalence, among those 235 women who screened positive and completed a CIDI, 67.2% met the criteria for a CIDI diagnosis, as did 16.9% of those who screened negative. The breakdown in CIDI diagnoses in the 235 women was 32.8% major depression (± anxiety disorder); 26.4% minor depression alone; and 8.1% with a primary anxiety disorder (approximately half with minor depression). Put another way, 20.4% of these women had an anxiety disorder (approximately two thirds with comorbid depression) and 37.7% of women with a major depressive episode (MDE) had a comorbid anxiety disorder. The estimated 6- to 8-month prevalence rate for a CIDI diagnosis of anxiety or depression (major or minor) was 29.2% (95% CI 26.7%-31.7%). The use of the "interval symptom" question alone was 1.7 times more likely to identify positive CIDI cases than the EPDS alone. Almost 40% of postnatal women with a diagnosis of MDE have a comorbid diagnosis of anxiety disorder. The estimated 6- to 8-month period prevalence for CIDI cases of anxiety and depression was 29.2%. Screening for anxiety and depression using the EPDS alone was associated with a lesser capacity to identify CIDI caseness than a simple "interval symptom" question (for the 2 months prior) which almost doubled the yield. This paper demonstrates that combining the EPDS with the "interval symptom" question improves detection of CIDI caseness.

Postnatal mental health of women giving birth in Australia 2002-2004: findings from the beyondblue National Postnatal Depression Program.

OBJECTIVES: To describe the postnatal mental health status of women giving birth in Australia 2002-2004 at 6-8 weeks postpartum. METHOD: Women were recruited from 43 health services across Australia. Women completed a demographic questionnaire and an Edinburgh Postnatal Depression Scale (EPDS) in pregnancy; the latter was repeated at 6-8 weeks following childbirth. RESULTS: A total of 12 361 postnatal women (53.8% of all postnatal women surveyed) completed questionnaires as part of a depression screening programme; 15.5% of women screened had a postnatal EPDS>9 and 7.5% of women had an EPDS>12 at 6-8 weeks following childbirth. There was significant variation between States in the percentage of women scoring as being potentially depressed. The highest percentage of women scoring EPDS>12 were in Queensland and South Australia (both 10.2%) while Western Australia had the lowest point prevalence (5.6%). Women recruited from private health services in Western Australia had a significantly lower prevalence of elevated EPDS scores than those women recruited from the public health service (EPDS >12: 3.6% vs 6.4%, p=0.026); differences in the prevalence of elevated EPDS scores were not significant between public and private in Australian Capital Territory (EPDS>12: 7.6% vs 5.8%, p=0.48), where income and education was significantly higher than other States for both groups. CONCLUSIONS: Postnatal depressive symptoms affect a significant number of women giving birth in Australia, and the point prevalence on the EPDS may be higher for women in the public sector, associated with lower incomes and educational levels. Maternity services--particularly those serving women with these risk factors--need to consider how they identify and manage the emotional health needs of women in their care. Specific State-related issues, such as availability of specialist perinatal mental health services and liaison between treating health professionals, also need to be considered.