Innovation for maternal mental health screening in South Africa

Common perinatal mental disorders (CPMD) are highly prevalent in low-income settings in South Africa. Research shows rates of depression between 32-47% during pregnancy and between 16-35% during the postnatal period,¹ which is approximately three times higher than in high-income countries.²  Untreated CPMD are directly linked to maternal mortality and morbidity³ and are associated with adverse outcomes for child health and development.⁴  Despite the evidence for effective psychosocial and pharmacological treatment,⁵ there are multiple gaps in the detection of CPMD at primary care level in South Africa.⁶

Gaps in detection and treatment

There are complex reasons for these gaps: 

(1) Primary health system resource issues:

Mental health care is not yet integrated into primary care in many settings, least of all into antenatal care, which makes early detection and intervention difficult.⁷ In most primary level clinics, antenatal care is provided by midwives and nursing assistants, who are often overwhelmed by high patient volumes and staff shortages. 

(2) Lack of screening instruments suitable to the context:⁸

Anecdotal evidence from the Perinatal Mental Health Project’s decade of work at Midwife Obstetric Units (MOU) in urban and peri-urban settings in Cape Town reveals that existing screening tools such as the EPDS may be too time-consuming and complicated to score for routine use by non-specialist health workers in busy settings.

Need for screening instruments

In response, the PMHP embarked on a research study to determine the optimal screening tool for use in low-resource, primary level antenatal settings. In order to meet the challenges of such settings the optimal screening tool was required to be brief, quick to administer, easy to score and interpret and relevant to the context. Additionally, it had to be clinically relevant without further overwhelming the system with false positives.

A battery of existing mood screening tools including the Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionnaire (PHQ9), Kessler Psychological Distress Scale (K10), Whooley Depression Screen and the revised Generalised Anxiety Scale (GAD-2) were analysed against a gold-standard diagnostic interview, the Mini-International Neuropsychiatric Interview (MINI-Plus). In addition a number of instruments to screen for psychosocial risk factors associated with CPMD were included in order to determine whether adding risk-screening items could enhance mood-symptom screening.

      Women are screened for symptoms

      of depression by non-specialist health

      workers during routine antenatal visits.

Outcomes of research

The outcome of analysis of the data revealed that anxiety disorders (23%) were as prevalent as depression (22%) in this sample. Short screening tools such as the three-item, binary-scoring Whooley Depression Screen performed as well as longer screening tools such as the EPDS and PHQ9 in detecting major depressive episode (MDE) and/or anxiety disorders in the sample.  The risk factor items that were associated with diagnosis data were:

(1) Difficult life events in the preceding year (losing someone close to me, losing my job, moving home etc.) 

(2) Past history of abuse (physical, emotional, sexual, rape)

Analyses of various combinations of the best-performing mood and risk screening items were conducted. The Whooley Depression Screen items emerged as top performers, with the combined three items yielding a sensitivity of 73% and specificity of 85%.

Conclusion 

The ultra-short Whooley Depression Screen shows promise as a screening tool for early detection in low-resource antenatal settings in South Africa.  In this context it   can be easily administered, scored and interpreted by non-specialist health workers.

What is novel about this finding is that an ultra short tool, with three items that are binary scoring may prove to be as useful as longer, more complex scored instruments. This may present a more feasible and acceptable tool for non-specialist health workers to use in routine antenatal care.

References:

1. Tsai, A. C., & Tomlinson, M. (2012). Mental health spillovers and the Millennium Development Goals : The case of perinatal depression in Khayelitsha, South Africa. Journal of Global Health, 2(1), 1–7.
2. Fisher, J., Mello, C. De, Patel, V., Rahman, A., Tran, T., & Holmes, W. (2012). Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bulletin of the World Health Organization, 90(November 2011), 139–149.
3. Oates, M. (2003). Perinatal psychiatric disorders: a leading cause of maternal morbidity and mortality. British Medical Bulletin, 67(1), 219–229.
4. Dunkel Schetter, C., & Tanner, L. (2012). Anxiety, depression and stress in pregnancy: implications for mothers, children, research, and practice. Current Opinion in Psychiatry, 25(2), 141–8.
5. van t’Hof, E., Cuijpers, P., Waheed, W., & Stein, D. J. (2011). Psychological treatments for depression and anxiety disorders in low- and middle-income countries: A meta-analysis. African Journal of Psychiatry, 14, 200-207.
6. WHO World Mental Health Consortium. Prevalence, severity and unmet need for treatment of mental disorders in the World Mental Health Organization world mental health surveys. JAMA 2004; 291: 2581–90.
7. Rahman, A. et al. (2013). Grand challenges: Integrating maternal mental health into maternal and child health programmes. PloS Medicine, 10(5), e1001442.  
8. Hanlon, C. (2012). Maternal depression in low- and middle-income countries. International Health, 5(1), 4–5.

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