LEGEND: The cost per case represents the total costs linked to one occurrence of perinatal mental health disorder (PMHD). The cost per birth represents the total costs for each disorder divided by total number of births, which represents the costs on average for PMHDs when averaged over the number of births in a specific area (e.g., Quebec province).

TO SCREEN OR NOT TO SCREEN: TAKING INTO ACCOUNT THE COSTS OF PERINATAL MENTAL HEALTH DISORDERS

The Québec Alliance for Perinatal Mental Health is composed of perinatal health clinicians and researchers, including psychiatrists, psychologists, psychotherapists, doulas, midwives, social workers, and nurses. On average, our members have more than 10 years of experience working in perinatal health, with many members specialized in perinatal mental health care. We share the Canadian Task Force on Preventive Health Care’s (CTFPHC) aim of using research to identify best practice in public health, especially for pregnant individuals, their partners, families, and children, however we disagree with their recent recommendation against screening for depression during the perinatal period using a validated questionnaire.

Notably, we disagree with the following conclusions made in their recent publication:

1) Should we stop using the Edinburgh Postnatal Depression Scale (EPDS) as a depression screening instrument during the perinatal period?

No. The CTFPHC paper assumes that most clinical care sites have properly trained personnel that can screen mental health symptoms -this is not the case in the province of Quebec or in the rest of Canada. In addition, the paper assumes that the use of the EPDS excludes or detracts from a clinical evaluation of mental health symptoms.

Rather, the EPDS helps health professionals to initiate a conversation about mental health during the perinatal period and tends to be followed by a more extensive clinical evaluation of mental health symptoms, as is the case for other health problems.

For example, the positive predictive value of cardiac auscultation for heart murmurs in children is also similar to that of the EPDS (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8318526/) and must be accompanied by an assessment of other clinical signs and symptoms and, potentially, by an echocardiogram. Yet no health care practitioner would suggest banning auscultation and physical examination from a clinical encounter altogether. Rather, a screening instrument should be used alongside other clinical tools at our disposal, and be accompanied by a relevant list of resources:

For more details, please see:

Greater Montreal area: https://www.antenatalwellbeingmtl.com/en-resources

Rest of the Quebec province: https://www.rcrpq.com

For international recommendations concerning perinatal mental health screening, please see:

https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/11/screening-for-perinatal-depression

https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-022-03694-9

2) When using the EPDS, or other validated screening tools, should we stop using cut-off scores altogether to determine the severity of depressive symptoms and to orient subsequent interventions?

No. It is important to note that cut-off scores used for research (e.g., EPDS >=10, mentioned by the CTFPHC’s paper) are lower than those used in clinical practice. In general, the lower the cut-off score, the higher the potential sensitivity to detect cases. This, however, is also associated with lower specificity (more false positives). This higher sensitivity with lower specificity is to be expected, and in fact, is a desired characteristic of a screening tool such as the EPDS, which is geared toward wide detection of cases rather than for confirmation of postpartum depression (PPD). The diagnosis of PPD can only be subsequently confirmed by a trained professional, but that is neither the intent nor the purpose of a screening tool.

In fact, the EPDS is comparable to other routine screening interventions recommended by Health Canada in terms of its sensitivity and specificity, e.g., the PSA test for prostate cancer or the QTc test for cardiovascular disorders. Serum, blood, and EKG results together with other clinical parameters are routinely used alongside these screening tools to formulate a clinical impression and treatment plan. In the same vein, the EPDS score should be routinely used along with other clinical parameters such mental status exam, personal and family history of psychiatric disorders, etc. in formulating a psychiatric impression and treatment plan.

3) Do the costs of screening outweigh the costs of not screening for mental health during the perinatal period?

No. The EPDS is freely available online in multiple languages and can be completed and scored by the pregnant or postpartum individual within 5-10 mins - in the time they spend waiting for their encounter with their health care professional.

In addition, as shown by Bauer et al., of the London School of Economics, the lifetime costs of perinatal mental health disorders are routinely under-estimated and, in order to understand their true economic burden, analyses should include not only the short-term costs to maternal mental health but also the long-term costs associated with loss of productivity, poor physical health, and compromised development and cardio-metabolic function in both mothers and children exposed to perinatal mood and anxiety disorders: http://eprints.lse.ac.uk/64685/2/Bauer_Lifetime%20costs_2015.pdf

Based on the Bauer framework, our group at McGill University has created a freely available tool to calculate the costs/benefits of perinatal mental health interventions: https://global-economic-calculator.herokuapp.com/.

This Canadian economic framework, supported by the Chamandy, Ludmer and Montreal General Hospital (MGH) Foundations suggests that the costs of not intervening during the perinatal period far outweigh the costs of detecting and treating perinatal mental health disorders.