Carry on screening

The need to detect and measure the wellbeing of women during pregnancy and in the postpartum period in order to assess the magnitude of the problem, to plan services and to respond to the needs of individual women and their families is recognised (Austin et al, 2008; Royal College of Psychiatrists, NICE, 2007). The aim of improving services for pregnant women and following the birth of a child has been and continues to be a driver in the development of policies and guidelines in this area (Oates, 2008).

Contemporary screening practice for postnatal depression involves a number of complex and unresolved, and possibly unresolvable, issues. The evaluation of established screening tools for PND such as the Edinburgh Postnatal Depression Scale (EPDS; Cox et al., 1987), has facilitated the identification of sub‐scales within the measure which may increase clinical screening efficacy or indeed, allow the identification of other psychological phenomena such as clinically relevant anxiety (Brouwers et al., 2001; Jomeen & Martin, 2005; Ross et al., 2003). Whether these derived scales and sub‐scales will prove clinically valuable only time and appropriate research studies will tell. The usefulness of the research endeavour into sub‐scale and new scale identification does not rest exclusively within the arena of clinical practice, and valuable insights into the nature of postnatal depression and indeed antenatal depression, the constellation of symptoms associated with it, and antecedent and related factors may be better explored in rather different kinds of studies that include, for example, longitudinal cohort studies. The ‘non‐identical clones’ of the original instruments used for measurement in this area may provide a basis and encouragement for a theoretical review of the underlying constructs, as well as enhancement and further clinical evaluation. The delivery of the best evidenced‐based care is facilitated by incremental instrument development, testing and evaluation, followed by appropriate revision. Cross national and cross cultural development and validation of instruments that can be used in diverse settings and in different languages demand further careful work with different populations and samples of a sufficient size to support rigorous construction and testing.

The thorough review undertaken by NICE (2007) covers mental health problems in pregnancy and following birth and includes: recognising mental health problems during pregnancy and in the first year after giving birth; the care and treatment (including drugs and psychological treatments) of women who develop a mental health problem during pregnancy or after giving birth; the care of women likely to develop a problem during pregnancy or the postpartum and that of women with a pre‐existing mental health problem and how families and carers may be able to support women with mental health problems.

However, the guideline explicitly suggests a departure from screening using a complete standard instrument such as the EPDS (Cox et al., 1987) for the screening of depression in the perinatal period and explicitly recommends two items derived from the 9‐item Patient Health Questionnaire (PHQ‐9; Spitzer et al., 1999) for initial screening, then a third question in the event of a positive response. The guidance currently is that at a woman’s first contact with primary care, at her booking visit and postnatally (usually at 4–6 weeks and 3–4 months), healthcare professionals (including midwives, obstetricians, health visitors and GPs) should ask two questions to identify possible depression:

•	During the past month, have you often been bothered by feeling down, depressed or hopeless?
•	During the past month, have you often been bothered by having little interest or pleasure in doing things?

A third question should be considered if the woman answers ‘yes’ to either of the initial questions:

•	Is this something you feel you need or want help with?

Following a positive response, NICE (2007) guidelines then suggests that healthcare professionals may consider the use of self‐report measures such as the EPDS, Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983) or PHQ‐9 (Spitzer et al., 1999) as part of further assessment, for monitoring outcomes and for routine follow‐up of individuals. This may create confusion for practitioners since they are confronted by guidelines that do not recommend a particular instrument and could perceive the use of a recognised instrument as optional. While women living in England may be affected by the guideline being put into practice in a sequential way, this is not the case for other parts of the UK. For women living in Scotland, alternative guidelines apply that specifically recommend the EPDS (Cox et al., 1987) for the screening of postnatal depression (Scottish Intercollegiate Guidelines Network; SIGN, 2002) based on extensive research evidence relating to its use. The efficiency and accuracy of the screening instrument used to detect symptoms of antenatal and postnatal depression may impact on the effectiveness of detecting for this type of mental health problem and could, with possible false negatives, delay intervention and treatment. Further research and audit on the use of these questions and complete psychological measures, with the associated outcomes, could provide more evidence on this point.

Debate of this kind about screening and measurement and the methods used may encourage the development of new instruments and tool‐kits that may better answer service and research needs in relation to identifying mental health problems in both populations and individual women, however at present it seems that we must carry on screening using the methods presently available.

While the Journal commonly has articles that directly involve the use of some of the measures mentioned, for example the recent paper by Parfitt and Ayers (2009) on post‐traumatic stress and depression, this edition covers a more diverse range of subjects and other psychological issues relating to body image before and after childbirth, the role of self‐efficacy when having a baby for the first time, adolescent recovery after childbirth, antenatal maternal stress and infant temperament, the distress of parents with an infant born with heart problems and the meaning of infertility to couples involved. These articles reflect some of the breadth of the Society of Reproductive and Infant Psychology interests and illustrate the value of qualitative and quantitative methods as well as the use and development of standard psychometric instruments enabling direct comparison across studies and in some instances countries.