Depression Screening

Fact Sheet and Resources

The World Health Organization states that depression is the leading cause of disability among women, accounting for $30–50 billion in lost productivity and direct medical costs annually in the US.

Depression during pregnancy can raise the risk of having a low–birth–weight baby and premature birth.

Screening pregnant women for depression enables health professionals to initiate services that can prevent later problems for both the mother and baby.

U.S. Preventive Services Task Force (USPSTF) Grade: B
USPSTF Recommendation:
Screen for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.¹

"Staff–assisted depression care supports" refers to clinical staff that assist the primary care clinician by providing some direct depression care, such as care support or coordination, case management, or mental health treatment."²

Depression - Provider Fact Sheet    PDF version - 98.48 KB

• Why is this important?
• How frequently is this preventive service being provided?
• What are the best screening practices identified in the literature?
• What are the best interventions identified in the literature?
• What barriers exist for providers?
• What are some ideas to address these barriers?
• What does the Affordable Care Act cover?
• What does Medicaid cover?
• References

For More Information

• Provider Implementation Tools
• Other Resources

Why is this important?

Depression is among the leading causes of disability in persons 15 years or older.³ It accounts for $30–50 billion in lost productivity and direct medical costs annually in the U.S.⁴

Major depression disproportionately affects women, with a lifetime prevalence of 21% and a female–to–male ratio of approximately 2:1.⁵ From 2006–2008, it is estimated that roughly 10% of adult women met the criteria for current depression.⁶ Major depressive episodes occur throughout a woman's lifespan, with highest rates occurring during the reproductive and menopausal transition years.⁷

According to a national survey, approximately 8% of pregnant women experienced major depression in the past year. And a CDC survey found that 8 to 19% of women reported having frequent postpartum depressive symptoms.⁸

Depressed mothers may have infants that display delayed psychological, cognitive, neurologic, and motor development. When a mother's depression is in remission children's mental and behavioral disorders improve.⁹

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How frequently is this preventive service being provided?

A 2012 nationally representative study found that more than half of pregnant (65.9%) and non-pregnant women (58.6%) experiencing depression went undiagnosed.¹⁰

According to a randomized cross-sectional survey of OB/GYNs who completed residency training during the previous 5 years, only 9% to 12% reported that they routinely asked patients about depression or used a screening questionnaire to identify major or minor depression.¹¹

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What are the best screening practices identified in the literature?

There is little evidence to recommend one screening method over another; therefore, clinicians may choose the method most consistent with the patient being served, the practice setting, and their personal preference.¹²

There are also insufficient data to recommend how often screening should be done. However, the American Academy of Pediatrics (AAP) recommends screening mothers for depression at the 1–, 2–, 4– and 6–month well–child visits and beyond the postpartum period.¹³

Using the 2–item patient health questionnaire (PHQ–2)¹⁴, which consists of 2 simple questions may be as effective as using more formal instruments:

• Over the past 2 weeks, have you felt down, depressed, or hopeless?
• Over the past 2 weeks, have you felt little interest or pleasure in doing things?

Other screenings identified by ACOG include, but are not limited to^*:

• PHQ–9 Patient Health Questionnaire [PDF] (often used as a follow–up to a PHQ–2 for those with a score of 2 or higher)
• Edinburgh Postnatal Depression Scale (EPDS)
• Postpartum Depression Screening Scale (PDSS)

Women with a positive screening assessment require follow–up evaluation and potentially treatment. Medical practices should have a referral process and follow–up protocol for identified cases.

^*See below "For more information" section to learn more about screening tools

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What are the best interventions identified in the literature?

A meta–analysis, looking at patients with depressive symptoms or diagnosed depressive disorders in primary care settings, showed that collaborative care interventions have a positive effect on medication adherence and depressive symptoms. Collaborative care interventions involve multifaceted care team approaches. The research shows that case manager expertise, supervision and recruitment by systemic identification are important characteristics for success.

The following were evaluated: Recruitment method, primary care physician training, case manager background (i.e. mental health vs. not), number of case manager sessions, case manager supervision, and case management content.

Results found that none of the individual variables impacted medication adherence; however, three of the variables had statistically significant impacts on depression outcomes:

The authors suggest that the effect of collaborative care on depressive symptom outcomes may be mediated by the use of antidepressants.¹⁵

Programs that reported improved outcomes were both self–contained within primary care and included specific follow–up, management, and therapy procedures; both resulted in the need for outside referrals in <10% of women diagnosed with postpartum depression.¹⁶

A full 12–month intervention that includes an initial engagement session, proactive outreach, and social service management may be needed in settings serving women with high poverty and comorbidities.¹⁷

More About Collaborative Care Models¹⁸

Collaborative care has shown increases in the number of patients using guideline–supported medication, improved mental health–related quality of life, and improved patient satisfaction with care.

Collaborative care models integrate a team of mental health specialists to support site clinicians in patient depression management. Allied health specialists, such as nurse care managers or social workers, are referred to and carry out enhanced depression interventions, serving as depression care managers for patients.

Depression care managers perform the following services:

Additionally, they may support women with social services or life skills, such as financial assistance with medications or housing, to ease life events stresses or problems which can reduce depressive symptoms. Problem–solving treatment–primary care, delivered by the depression care managers–has been proven to be as effective as antidepressants for primary care patients with major depressive disorder.

Collaborative care models typically include team management, tracking systems, and weekly structured case reviews with a psychiatrist, depression care manager, and site clinician.

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What barriers exist for providers?

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What are some ideas to address these barriers?

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What does the Affordable Care Act cover?

All Marketplace plans and many other plans must cover depression screening for adults without charging a copayment or coinsurance. This is true even if the patient has not met their yearly deductible. This applies only when these services are delivered by a network provider.²⁶

The Centers for Medicare and Medicaid Services (CMS) also provides information about the Coverage of Preventive Services.

HealthCare.gov provides lists of preventive care benefits for all adults and those specific to women.

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What does Medicaid cover?

Each state has its own plan for Medicaid coverage. To find out more about Medicaid and CHIP eligibility and coverage in your state, please visit Medicaid.gov.

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• recruitment by systematic identification (p=.061),
• case managers having a specific mental health background (p=.004), and
• provision of regular supervision for case managers (p=.033)
• provide evidence–based psychotherapy
• track patient treatment responses, medications, and compliance
• distribute written depression educational materials.
• Lack of tools to improve depression management, lack of time and support in the practice setting for managing patients with depression.¹⁹
• Primary care and other health practices are not well organized for this purpose and need better systems for tracking patients, encouraging follow up, and assigning appropriate people in the practice to assist the physician.²⁰
• Clinicians may have perceived barriers for screening and treating depression, including inadequate training and lack of resources for follow–up care.²¹
• Establish referral networks to ensure effective treatment and follow&ndahsup.²²
• Develop office routines and practice patterns that could improve management of patients with depression.²³
• Develop educational programs and tools to help primary care physicians better recognize and care for patients with depression. Evaluate the impact of these practices, programs, and tools.²⁴
• Conduct focus groups of mental health providers to determine relative awareness of these barriers, followed by education sessions of the greater community mental health provider network regarding potential solutions.²⁵

For more information

Provider Implementation Tools

Perinatal Depression Screening: Tools for Obstetrician–Gynecologists [PDF] is an American College of Obstetricians and Gynecologists (ACOG) toolkit offering relevant provider education regarding perinatal depression. The toolkit includes the following: Perinatal Depression Screening Tool; Assessment and Management Strategies; Pharmacologic Chart; and List of Relevant Provider and Patient Resources.

Screening Tools listed by ACOG in the Committee Opinion: Screening for Perinatal Depression:

Depression During Pregnancy: Treatment Recommendations are offered by ACOG and American Psychiatric Association (APA); this website provides the full report here.

ACOG Guidelines on Psychiatric Medication Use During Pregnancy and Lactation

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Other Resources

•  PHQ–9 Patient Health Questionnaire [PDF]
•  Edinburgh Postnatal Depression Scale [PDF] consists of ten short statements with four possible responses. This scale was originally used in the postpartum period only, however, numerous studies validate its use throughout the perinatal period, including the first trimester.
•  The Beck Depression Inventory (BDI) [PDF] is a 21–item, self–report rating inventory that measures characteristic attitudes and symptoms of depression.
•  Center for Epidemiologic Studies Depression Scale (CES–D) [PDF]

ACOG: Screening for Perinatal Depression is a Committee Opinion reported dated May 2015 that reflects emerging clinical and scientific advances and is subject to change; report information should not be construed as dictating an exclusive course of treatment or procedure to be followed. The report describes multiple depression screening tools available for use, however, indicates that no firm recommendation exists for a universal screening tool.

Office on Women's Health (OWH) Depression during and after pregnancy fact sheet is an informational tool for patients

Health Resources and Services Administration (HRSA) Depression During & After Pregnancy is a resource for women, their families, and friends.

American Psychiatric Association Postpartum Depression information 

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