Perinatal depression — depression occurring during pregnancy or in the first year after birth — affects approximately 12% of women globally, with prevalence estimates ranging from 8.9% to 37% depending on when and how it is measured.1 Anxiety disorders during pregnancy are at least as common. Yet screening rates remain inadequate: studies show that more than a third of pregnant women in some health systems are never screened for depression at any prenatal visit.2 This is not a gap in medical knowledge. Every major clinical body recommends screening. It is a gap in implementation.
What the guidelines say
ACOG (American College of Obstetricians and Gynecologists) recommends that screening for perinatal depression and anxiety occur at the initial prenatal visit, later in pregnancy, and at postpartum visits, using a standardised, validated instrument.3 ACOG's 2023 Clinical Practice Guideline on screening and diagnosis of mental health conditions during pregnancy and postpartum provides a comprehensive framework, including composite screeners that combine depression, anxiety, bipolar, and PTSD screening tools.
The USPSTF (US Preventive Services Task Force) recommended screening for perinatal depression in 2016 and, in 2019, additionally recommended that counselling interventions be provided to those at risk.4
NICE in the UK recommends that healthcare professionals ask about mental health at every antenatal contact, using the Whooley questions as an initial screen, with validated tools such as the EPDS or PHQ-9 for further assessment.
The screening tools
Edinburgh Postnatal Depression Scale (EPDS) — a 10-item self-report questionnaire specifically designed for perinatal use. It addresses both depressive symptoms and the anxiety component of perinatal mood disorders. A score of 10 or above is the standard cutoff suggesting possible depression. Critically, it includes a question about self-harm (question 10), which requires immediate follow-up regardless of total score. The EPDS is the most widely used perinatal screening tool globally.5
Patient Health Questionnaire-9 (PHQ-9) — a 9-item questionnaire based on the DSM diagnostic criteria for major depression. A meta-analysis of 10 criterion validity studies using the standard cutoff of 10 or above in perinatal populations showed pooled sensitivity of 0.84, specificity of 0.81, and AUC of 0.89.6 The PHQ-9 does not include an anxiety component but does include suicidal ideation (question 9). It is useful because its items map directly onto DSM diagnostic criteria, facilitating communication with mental health providers.
Generalised Anxiety Disorder-7 (GAD-7) — a 7-item anxiety screening tool. ACOG recommends it alongside the EPDS or PHQ-9 because anxiety is increasingly recognised as one of the most common presenting symptoms of perinatal mood and anxiety disorders. A score of 10 or above suggests clinically significant anxiety.3
ACOG's Lifeline for Moms programme has developed composite screeners that combine the EPDS or PHQ-9 with the GAD-7, the Mood Disorder Questionnaire (MDQ) for bipolar screening, and the PC-PTSD-5 for trauma screening — providing a comprehensive mental health assessment in approximately five minutes.3
What the scores mean
Screening scores are not diagnoses. A score above the threshold (typically 10 on the EPDS, PHQ-9, or GAD-7) indicates that further clinical assessment is needed — a conversation with a provider, not a label. Scores below the threshold do not guarantee the absence of a mood disorder, particularly because pregnancy-related symptoms (sleep disruption, appetite changes, fatigue) overlap with depression criteria and can reduce specificity.6
What matters most is not a single score but the pattern over time. Repeated screening across pregnancy and postpartum captures the fluctuating nature of perinatal mood disorders. A score that rises from 6 to 14 between the second and third trimester is clinically significant even if the first score was below threshold.
Why screening matters
Untreated perinatal depression is associated with preterm birth, low birthweight, impaired maternal-foetal bonding, disrupted breastfeeding, and adverse child developmental outcomes. It is also the leading cause of maternal death in high-income countries when suicide is included.7 Screening identifies women who would otherwise suffer in silence — particularly those who assume that feeling terrible during pregnancy is normal and to be endured.
If your provider has not screened you using a validated tool during pregnancy, ask for it. The EPDS and PHQ-9 are freely available, take five minutes to complete, and could be the most important five minutes of your prenatal care.
