Anxiety is a common experience for many women, particularly during the perinatal period – the time spanning pregnancy and the first year after birth.
This phase involves significant physical, emotional, and lifestyle changes that can trigger or exacerbate anxiety symptoms.
Perinatal anxiety affects 15-20% of women and can have profound impacts on maternal well-being, fetal development, and infant outcomes.
It has been linked to increased risks of preterm birth, postnatal depression, and difficulties in infant emotional development.
Despite its prevalence and potential consequences, perinatal anxiety often goes unrecognized and untreated.
Studying perinatal anxiety is crucial to develop effective screening methods, improve early identification of at-risk women, and implement timely interventions to support maternal mental health and promote positive outcomes for both mothers and babies.
Ayers, S., Sinesi, A., Coates, R., Cheyne, H., Maxwell, M., Best, C., . McNicol, S., Williams, L. R., Uddin, N., Shakespeare, J., Alderdice, F., & MAP Study Team. (2024). When is the best time to screen for perinatal anxiety? A longitudinal cohort study. Journal of Anxiety Disorders, 103, 102841. https://doi.org/10.1016/j.janxdis.2024.102841
Key Points
- Early pregnancy (around 11 weeks gestation) was found to be the optimal time to screen for perinatal anxiety to identify women with anxiety disorders and those wanting treatment.
- This finding was consistent across all five questionnaires examined (GAD-2, GAD-7, SAAS, CORE-10, Whooley questions).
- Anxiety symptoms were highest in early pregnancy and decreased over time.
- Receiving treatment was most strongly associated with anxiety screening in late pregnancy or postnatally.
- The research provides important evidence to inform clinical practice, policy, and further research on perinatal anxiety screening.
- While informative, the study has limitations such as potential selection bias and data collection during the COVID-19 pandemic.
Rationale
Perinatal anxiety affects 15-20% of women and can have significant impacts on maternal and infant outcomes (Dennis et al., 2017; Fawcett et al., 2019).
However, there is a lack of consensus on whether and how to screen for perinatal anxiety (Chaudron & Wisner, 2014; Thombs et al., 2017).
Key questions remain about the optimal timing of screening and which questionnaires are most effective.
This study aimed to address these gaps by examining the optimal time to screen for perinatal anxiety to identify women with anxiety disorders and those wanting treatment.
It also sought to examine the stability and change in perinatal anxiety over time. Providing evidence on these issues is crucial to inform clinical practice, policy, and further research on perinatal mental health screening and care.
Method
The study used a prospective longitudinal cohort design with 2243 women completing questionnaires at four timepoints: early pregnancy (11 weeks), mid-pregnancy (23 weeks), late pregnancy (32 weeks), and postnatally (8 weeks). A subsample of 403 participants also completed diagnostic interviews.
Procedure
Participants completed five anxiety/mental health questionnaires at each timepoint. A subsample underwent diagnostic interviews using the Mini International Neuropsychiatric Interview (MINI) to establish the presence of anxiety disorders.
Sample
The sample was representative of the general UK population in terms of ethnicity, age, and relationship status, but more highly educated.
The majority were white British, educated to degree level or above, and married or cohabiting.
Measures
- GAD-7 and GAD-2: Seven- and two-item scales respectively that measure symptoms of generalized anxiety disorder.
- Stirling Antenatal Anxiety Scale (SAAS): A 10-item scale specifically designed to assess perinatal anxiety, including both general and pregnancy-specific anxiety.
- Clinical Outcomes in Routine Evaluation (CORE-10): A 10-item measure of general psychological distress, including depression, anxiety, trauma, physical problems, and risk to self.
- Whooley questions: Two brief questions designed to screen for depression in primary care settings.
- Mini International Neuropsychiatric Interview (MINI): A structured diagnostic interview used to assess the presence of various psychiatric disorders according to DSM criteria.
Results
- Early pregnancy screening had the highest diagnostic accuracy for identifying anxiety disorders across all questionnaires.
- Early pregnancy screening was most predictive of women wanting treatment at any point during pregnancy or postnatally.
- Anxiety symptoms were highest in early pregnancy and decreased over time.
- Receiving treatment was most strongly associated with anxiety screening in late pregnancy or postnatally.
Insight
This study provides crucial evidence that early pregnancy (around 11 weeks) is the optimal time to screen for perinatal anxiety.
This finding was consistent across all questionnaires examined and for both identifying anxiety disorders and women wanting treatment.
The results suggest that implementing anxiety screening in early pregnancy could help identify women who need support earlier, potentially improving outcomes.
The finding that anxiety symptoms were highest in early pregnancy adds to the literature on the course of perinatal anxiety, though individual variation was observed.
The association between late pregnancy/postnatal screening and receiving treatment highlights potential delays in referral or access to treatment, emphasizing the need for timely follow-up after early screening.
Strengths
This study had several methodological strengths, including:
- A large sample size (2243 women)
- Longitudinal design with four timepoints
- Use of diagnostic interviews with a subsample
- Examination of multiple questionnaires
- Consideration of both diagnosed anxiety disorders and self-reported desire for treatment
Limitations
This study also had several methodological limitations, including:
- The sample was more highly educated than the general population
- Possible selection bias with anxious women more likely to participate
- Data collection during the COVID-19 pandemic may have influenced anxiety levels and treatment access
- Diagnostic interviews were only conducted at one timepoint per participant
- The study did not measure referrals, making it difficult to determine reasons for delays in treatment
Implications
The findings have clear implications for clinical practice and policy. They support implementing anxiety screening in early pregnancy, around 11 weeks gestation, which often coincides with initial maternity care appointments in many countries.
This consistency across questionnaires simplifies implementation, as services can continue using their current screening tools but ensure they are administered early.
However, screening is only an initial step and must be followed by further assessment and appropriate treatment.
The study highlights the need for timely follow-up and referral after early screening to address the observed delay between screening and treatment.
Future research should examine the effectiveness of early pregnancy screening as part of a comprehensive care pathway for perinatal anxiety.
References
Primary reference
Ayers, S., Sinesi, A., Coates, R., Cheyne, H., Maxwell, M., Best, C., . McNicol, S., Williams, L. R., Uddin, N., Shakespeare, J., Alderdice, F., & MAP Study Team. (2024). When is the best time to screen for perinatal anxiety? A longitudinal cohort study. Journal of Anxiety Disorders, 103, 102841. https://doi.org/10.1016/j.janxdis.2024.102841
Other references
Chaudron, L. H., & Wisner, K. L. (2014). Perinatal depression screening: Let’s not throw the baby out with the bath water! Journal of Psychosomatic Research, 76(6), 489–491. https://doi.org/10.1016/j.jpsychores.2014.03.011
Dennis, C. L., Falah-Hassani, K., & Shiri, R. (2017). Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis. The British Journal of Psychiatry, 210(5), 315-323.
Fawcett, E. J., Fairbrother, N., Cox, M. L., White, I. R., & Fawcett, J. M. (2019). The prevalence of anxiety disorders during pregnancy and the postpartum period: a multivariate Bayesian meta-analysis. The Journal of clinical psychiatry, 80(4), 1181.
Thombs, B. D., Saadat, N., Riehm, K. E., et al. (2017). Consistency and sources of divergence in recommendations on screening with questionnaires for presently experienced health problems or symptoms: a comparison of recommendations from the Canadian Task Force on Preventive Health Care, UK National Screening Committee, and US Preventive Services Task Force. BMC Medicine, 15, 150. https://doi.org/10.1186/s12916-017-0903-8
Keep Learning
Below are some questions that can be discussed in a college class:
- How might cultural factors influence the optimal timing and effectiveness of perinatal anxiety screening?
- What are the potential ethical considerations of implementing early pregnancy anxiety screening?
- How can healthcare systems balance the benefits of early screening with the potential for increased anxiety or false positives?
- What strategies could be implemented to ensure timely follow-up and treatment access after early screening?
- How might the findings of this study be applied or adapted in low-resource settings or countries with different maternity care structures?
