A call to re-visit recommendations for instrument-based perinatal depression screening in Canada: commentary on Lang et al., 2022:
References
https://doi.org/10.3389/fpsyt.2022.929496
https://doi.org/10.1001/jama.2015.18948
https://doi.org/10.1093/pubmed/fdq075
https://canadiantaskforce.ca/guidelines/upcoming-guidelines/depression-in-pregnancy-and-postpartum/
https://doi.org/10.1080/09540261.2018.1534725
As a national group of perinatal mental health experts, we pointedly object to the Canadian Task Force for Preventative Health Care’s (CTFPHC) position against instrument-based screening for depression during the perinatal period and disagree with the conclusions drawn from the Lang et al article.
“Usual care” does not adequately include inquiry and attention to perinatal mental health.
The CTFPHC assumes that usual care includes attention to mental health, but this is not the case. Perinatal mental health needs are under-addressed. In a recent survey of over 400 perinatal service providers, 57.3% lacked mental health training, 87% reported a lack of mandated provincial mental health screening of any type, and 95.8% identified that there were insufficient services to address mental health needs (1).
Appropriate use of instrument-based screening provides more benefits than risks.
We counter the conclusion that evidenced-based screening provides more risks than benefits. A similar systematic review by the U.S. Preventive Services Task Force’s (USPSTF) notes no deleterious effects of screening (2). Further, the RCT (3) included by the CTFPHC clearly states that “no adverse events were reported.” Even more concerning, the “no screen” recommendation conflicts with patient preferences described in Burnett et al., (4), where participants clearly stated that the benefits of screening outweigh any potential risks.
The evidence in favor of instrument-based screening is emergent, yet clear.
We view the CTFPHC’s conclusion, that “the evidence in favour of instrument-based screening for perinatal depression is very uncertain,” as inadequate because their narrow inclusion criteria for evidence resulted a recommendation largely reliant on a single article that is over 10 years old. In contrast, the USPSTF review found that across six trials, more perinatal women who participated in a screening program for depression saw a greater reduction in depressive symptoms (18 – 59%) versus those who received usual care (2).
Current CTFPHC recommendations are likely to cause harm and worsen inequities.
Despite up to 25 contacts with providers, 50% of perinatal people with mental health concerns are not diagnosed and only 15% of those in need receive appropriate treatment referrals (5). Without standardized screening, the burden is placed on patients to bring their symptoms to the attention of providers. This approach too often fails patients, because shame, avoidance and withdrawal are core depression symptoms that can make it difficult for patients to disclose their needs.
We appreciate that the CTFPHC has highlighted the topic on instrument-based screening in perinatal mental health but disagree with methods and conclusion of their review. We aim to call attention to the critical importance of improving mental health screening, assessment, and treatment and move towards our shared goal of supporting birthing individuals and their children.