South African Psychiatry - November 2018

FEATURE
Screening can generate controversy, however
sufficient data exists to support the introduction
of screening for perinatal depression and anxiety.
Perinatal depression meets most of the criteria for
the implementation of a screening program.
THE CONDITION IS SERIOUS, PREVALENT,
TREATABLE AND ACCEPTABLE TESTS OF
KNOWN ACCURACY ARE AVAILABLE.
THERE ARE MULTIPLE TOOLS FOR USE
INCLUDING GENERIC SELF-REPORT
TOOLS FOR DEPRESSION SCREENING
AND PERINATAL-SPECIFIC SELF-REPORT
TOOLS.
Some widely used screening tests that have been
validated in perinatal populations including
women in South Africa, include the Edinburgh
Postnatal Depression Scale (EPDS), Patient Health
Questionnaire–9 (PHQ-9) and case finding
questions such as the Whooley questions. The
PHQ-9 is a commonly used generic self-report
four-point Likert-type scale questionnaire used
in primary health care settings. The EPDS is a
perinatal-specific self-report 10-item 4-point Likert
scale. It is brief, and the most widely used tool used
for both antenatal and postnatal depression. The
Whooley questions are two case-finding questions
that require only a yes or no response. They can
identify anxiety and depression with reasonable
accuracy.
THEY ARE SHORT AND DO NOT
REQUIRE LITERACY, OR SCORING AND
INTERPRETATION LIKE PENCIL AND
PAPER TESTS, AND SO ARE MORE TIME-
EFFECTIVE. THESE TWO QUESTIONS
ADDRESS SYMPTOMS OF DEPRESSION
THAT ARE NECESSARY BUT NOT
SUFFICIENT TO MAKE A DIAGNOSIS OF
DEPRESSION: “DURING THE PAST MONTH,
HAVE YOU OFTEN BEEN BOTHERED
BY FEELING DOWN, DEPRESSED OR
HOPELESS?” AND “DURING THE PAST
MONTH, HAVE YOU OFTEN BEEN
BOTHERED BY LITTLE INTEREST OR
PLEASURE IN DOING THINGS?”
General clinical recommendation suggest that:
• Screening should be conducted in order
to increase identification of cases, which
subsequently should improve outcomes.
• The screening should ideally be completed in
the presence of a health care professional.
• Ask about and assess psychosocial risk factors
such as unemployment, and lack of partner
support.
• Short, simple screening tools with high sensitivity
should be used and followed-up with tools with
high specificity ie: The Whooley case finding
questions first and then the EPDS.
• Screening can occur anytime pre- or postnatally.
Recommendations are that postnatal screening
be conducted between 4 and 12 weeks
postnatally.
• Screening should take place in settings that
are acceptable to women. Ensure the women’s
privacy and a non-judgmental environment
and explain why you are doing the screening;
and what the results mean.
• Once screening is implemented it is vital to have
a plan and resource for diagnosis, management
and follow-up and referral if needed. Be prepare
to address suicidality and have an emergency
plan in place to assist suicidal women.
• A screening test must never replace clinical
judgment
CONCLUSION
Currently there are few routine mental health
programmes; or even guidelines for screening
perinatal women in South Africa in the public sector,
despite evidence showing that these programmes
can be effectively introduced to a primary health
care setting.
AS A RESULT, PERINATAL MENTAL HEALTH
PROBLEMS REMAIN UNDER DIAGNOSED
AND ARE LEFT UNTREATED IN THE MAJORITY
OF CASES. WHAT IS NEEDED IS THE
DEVELOPMENT AND IMPLEMENTATION
OF EFFECTIVE PERINATAL MENTAL
HEALTH POLICIES, WHICH WILL HELP
PROTECT AGAINST ADVERSE AFFECTS OF
PERINATAL DEPRESSION AND ANXIETY
IN A SIGNIFICANT NUMBER OF SOUTH
AFRICAN WOMEN.
In the meantime however, it is up to the individual
health care provider to be aware of the severity of
the problem and to make it a habit to screen all
perinatal women for depression and anxiety.
References available from the author
Carina Marsay is a specialist psychiatrist. She obtained
her FC Psych (SA) in 2009 and her MMed (Psych) in 2010.
Dr Marsay has a PhD from the University of Witwatersrand
related to her work in perinatal psychiatry and is an honorary
appointee in the Department of Psychiatry at Wits. She is
a recipient of the MRC Clinician Researcher Programme
Scholarship. Dr Marsay has an interest in perinatal psychiatry
and is a member of the International Marcé Society,
an organisation dedicated to perinatal mental health.
Correspondence: carinamarsay@gmail.com
If you would like to know more, please have a look at
what the Perinatal Mental Health Project are doing
for women in South Africa: https://pmhp.za.org/
20 * SOUTH AFRICAN PSYCHIATRY ISSUE 17 2018