To screen or not to screen:

that is indeed the question.

John Cox, BM, BCh DM (Oxon) FRCPsych

Professor Emeritus Keele University, StaffordshirePast President Marce Society and Royal College

of Psychiatrists.John1.cox @virgin .net

Introduction:Contemporary issues Speed of cultural changes in UK.Individualistic ,competitive , materialistic, market driven. Yet 25th Anniversary of the PBU!NHS 65th anniversary!

EBM and VBM; evidence and Values.Lack of relationship based Person Centered health care

1986

A public health service in which members of a defined population, who do not necessarily perceive that they are at risk of, or are already affected by a disease or its complications, are asked a question or offered a test to identify those individuals who are more likely to be helped than harmed by further tests or treatments reduce the risk of disease or its complications (National Screening Committee 2000)

Criteria for appraising programmes:

An important health problem Natural History of the condition

understood. All primary prevention interventions have

been implemented

Simple Safe precise and validated Acceptable to the population Agreed policy on further diagnostic

investigations following a positive screen.

An effective intervention. Evidence that early treatment is advantageous.

Evidence-based policies about which treatment option

Patient management options optimised prior to screening.

There must be evidence from the high quality RCTs that the screening programme is effective in reducing morbidity and mortality.

The programme is acceptable to the public and the professionals.

Benefits outweigh the risks

National Institute of Clinical Excellence. Antenatal and Postnatal Mental Health Guidelines.

Mental disorders during pregnancy and the postnatal

period

Severe mental illness

Schizophrenia

Bipolar disorder

Depression

Mild, moderate or severe

Anxiety disorders

Panic disorder

Generalised anxiety disorder

Obsessive–compulsive disorder (OCD)

Post-traumatic stress disorder (PTSD)

Eating disorders

•Need to develop new classifications of

perinatal mental disorder ICD-11 and DSM-5

eg mandatory 3 months specifier.

???

Prediction

At first contact with maternity services, ask specific questions about:

•Past or present severe mental illness

•Previous treatment by psychiatrist/specialist mental health team

•Family history of perinatal mental illness

???•Risk factors well-established for over 30 years.

•Why have the midwifery profession and the medical profession not acted?

•Why have obstetricians in the UK no postgraduate training in mental health?

Detection

•Use the ‘Whooley’ questions at first contact with primary care, at the booking visit, and postnatally

•Other self-report measures can be used as part of subsequent assessment

Identify possible depression

???•No established evidence-base for the Whooley questions yet!

•Are they too woolly?!

•Evidence for use of screening scales such as the EPDS considerably more conspicuous!

The ‘Whooley’ questions

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?

Consider a third question:

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

Psychosocial treatmentsprovide treatment within 1 month of

initial assessment

Subthreshold symptoms

•Previous depression or anxiety

4–6 sessions of brief psychological treatment such as interpersonal therapy (IPT) or cognitive behavioural therapy (CBT)

• No previous depression or anxiety

Social support such as regular informal individual or group-based support

Management of depression

Mild or moderate depression

• Self-help strategies

• Counselling (listening visits)

• Brief cognitive behavioural therapy

• Interpersonal psychotherapy

•Is it the content of the therapy, or its regularity by a usually female professional, that is effective?

•Is the health visitor, children’s nurse or psychologist providing the empathic support traditionally given by the mother?

???

Organisation of care

• Effective detection

• Effective assessment and referral to appropriate services

• Timely, appropriate management and treatment

• Accurate information about the disorder and the benefits and risks associated with interventions

• Provision of care in the most appropriate setting

• Appropriate communication about care with other services as required, taking into account confidentiality

• Choice

???•Ethics of screening

•National screening committee controversy with regard to the EPDS

Service delivery:perinatal mental health

networks•Coordinating board

•Specialist perinatal services in each locality providing direct services, consultation and advice

•Access to specialist expert advice on psychotropic medication

•Clear referral and management protocols

•Clearly defined roles and competencies for all professional groups

•Clearly defined pathways of care for service users

The Evidence Base:

Research and Values relevant to my own international work

Kasangati Health Centre Antenatal Clinic

Antenatal interview: Eunice Sendagire Postnatal interview: Charles Kimbugwe

(Lancet)

Kendell et al 1987.

New onset depressions Cox, Murray and Chapman 1993

Identifying Perinatal DepressionListen to what the mothers are telling you‘I have never felt like this before’It was ‘terrible’ ‘absolutely ghastly’ ‘something had got a hold’

Screening Tools / Tests eg Edinburgh

Postnatal Depression Scale

Cox JL, Holden JM, Sagovsky R (1987): Detection of PostnatalDepression. Development of the 10-Item Edinburgh PostnatalDepression Scale. British Journal of Psychiatry, 150, p782-786

Cox JL, Holden JM, Henshaw, C (2013): Perinatal Mental Health:The Edinburgh Postnatal Depression Scale (EPDS) ManualSecond Edition. RCPsych Publications. In Press

As you have recently had a baby, we would like to know how you are feeling

now. Please underline the answer which comes closest to how you have felt

in the last 7 days, not just how you feel today.Here is an example , already completed:

I have felt happy: Yes, most of the time Yes, some of the time No, not very often No, not at all

This would mean: “I have felt happy some of the time during the past week.

Please complete the other questions in the same way

IN THE PAST SEVEN DAYS

1. I have been able to laugh and see the funny side of things:

As much as I always could 0 Not quite so much now 1 Definitely not so much now 2 Not at all 3

2. I have looked forward with enjoyment to things:

As much as I ever did 0 Rather less than I used to 1 Definitely less than I used to 2 Hardly at all 3

3. I have blamed myself unnecessarily when things went wrong:

Yes, most of the time 3 Yes, some of the time 2 Not very often 1 No, never 0

4. I have been anxious or worried for no good reason:

No, not at all 0 Hardly ever 1 Yes, sometimes 2 Yes, very often 3

5. I have felt scared or panicky for no very good reason:

Yes, quite a lot 3 Yes, sometimes 2 No, not much 1 No, not at all 0

6. Things have been getting on top of me: Yes, most of the time I haven’t been able to cope at

all well 3 Yes, sometimes I haven’t been coping as well as

usual 2 No, most of the time I have coped quite well

1 No, I haven’t been coping as well as ever

0

7. I have been so unhappy that I have had difficulty sleeping:

Yes, most of the time 3 Yes, sometimes 2 Not very often 1 No, not at all 0

8. I have felt sad or miserable: Yes, most of the time 3 Yes, quite often 2 Not very often 1 No, not at all 0

9. I have been so unhappy that I have been crying:

Yes, most of the time 3 Yes, quite often 2 Only occasionally 1 No, never 0

10. The thought of harming myself has occurred to me:

Yes, quite often 3 Sometimes 2 Hardly ever 1 Never 0

• Norwegian • Greek• Italian • Hebrew• Portuguese • Slovenian• Chinese • Urdu• French • Vietnamese• Swedish • Hindi• Icelandic• Nepalese• Turkish

Gibson et al 2009; Cox and Holden 2003 (Current count 54)

• German

• Spanish

• Arabic

• Maltese

• Japanese

• Dutch

• Punjabi

• Congolese

• Bangla

• Danish

• Taiwanese

• Finish

• Maori

• Ethiopian

• Nigerian

• Psychometric Properties

• False Positives; False Negatives

GLOBAL SCREENING ISSUES eg

Australia England

Sweden Several US States

Scotland Norway

Iceland Canada

Henshaw, C, Elliott, S (Eds) 2005: Screening for Postnatal Depression

Jessica Kingsley, London

Naturalistic validation studies of screening scales

Controlled prevalence studies of antenatal and postnatal mood disorder

Control studies of targeted screening programmes including cost benefit analysis

Qualitative studies of effect of perinatal mood disorder on relationship hassles

Evaluating principles of accessibility for all

Conceptual understanding of the priority of childbearing-related mental health issues

This talk is in part derived from my recent paper published in the International Journal of Person-Centred Medicine (2012): Conceptual and Treatment Approaches for a Revitalised Health Service and Renewed Person-Centred Perinatal Psychiatry, Issue 1, p109-113